Science-Based Medicine

SBM's logo and tagline.

This might be Skepticism

But we're not sure

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Who's asking?

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Science-Based Medicine (or SBM) is a group blog about medicine written from a skeptical viewpoint. As a result, a lot of its content deals with alternative medicine claims.

SBM was founded by Steven Novella, MD.^[1] It is owned by the New England Skeptical Society (the NESS); Novella is also the NESS's current president as well as one co-founder. In 2020, the blog became part of the Center for Inquiry (CFI) — Quackwatch also joined the CFI that year.^[2][3]

Premise[edit]

The title of the blog reflects one of its goals. The editors of SBM argue, essentially, that the evidence-based medicine (EBM) movement sometimes hasn't been comprehensive enough in taking the full range of scientific knowledge into consideration when making decisions. A key proposal of SBM is for EBM to consider whether treatments have "plausibility" (or "prior probability"),^[4] based on scientific principles. In a 2015 article for Skeptical Inquirer on this subject, Steven Novella wrote:^[5]

Don't get me wrong: modern medicine is a science-based endeavor. We continue to make tremendous, even accelerating, progress in understanding and treating disease. The institutions of science and the professionalism within medicine are also improving over time. The evidence-based medicine (EBM) movement has been, overall, a positive influence on the practice of medicine. ... EBM is great as far as it goes, but it has some interesting flaws, and clearly has not done enough to eradicate pseudoscience and substandard practice from medicine. That is exactly why I founded the website Science-Based Medicine ... The goal of science-based medicine (SBM) is to raise the practice of medicine to the highest standards possible, relying on the full spectrum of scientific evidence; raising the application of critical thinking to the practice of medicine; optimizing the institutions of science, research, and academia; rooting out pseudoscience and quackery; and advocating for effective regulations.

The core weakness of evidence-based medicine is that it relies, as the name implies, solely on clinical evidence to determine whether a treatment is appropriate or not. This may superficially sound reasonable, but it deliberately leaves out an important part of the scientific evidence: plausibility. When EBM was first proposed, the idea was that doctors should not be using treatments simply because they make sense. We need evidence to show that the treatments are actually safe and effective. This is reasonable, but their solution was to eliminate "making sense" (or plausibility) from the equation. Each treatment was considered conceptually as a blank slate or with a level playing field—the only thing that mattered was the clinical evidence. Unfortunately, the EBM movement came at roughly the same time that dubious health practices were being rebranded as "complementary and alternative medicine" (CAM). By leveling the playing field, EBM inadvertently removed the primary objection to most CAM modalities: that they are highly implausible. I guess it did not occur to early EBM proponents that anyone would seriously propose a highly implausible treatment and try to study it scientifically. CAM proponents fell in love with EBM, because it gave them the opportunity to present their treatments with a veneer of scientific legitimacy. They tend to interpret EBM as meaning that if you can point to any evidence whatsoever (no matter how poor and conflicting), then you can call your practice "evidence-based."

One of the standard bearers for EBM is the Cochrane Collaboration ... Cochrane reviews quickly became ripe for CAM exploitation. My favorite example is a Cochrane review of homeopathic substance Oscillococcinum for the flu (Vickers and Smith 2009). Oscillococcinum is imaginary, and homeopathy is utter nonsense, so this treatment is akin to fairy dust diluted out of existence. If anything should be treated as having a prior plausibility of zero, this is it. Yet the authors ... characterize the treatment as 'promising' and recommend 'further research.' SBM would take a different approach. A science-based medicine review would explicitly consider prior scientific plausibility, bringing to bear our understanding of physics, chemistry, and biology, which represent a far larger and more reliable body of scientific evidence than the few clinical studies of Oscillococcinum. It would also consider the totality of homeopathy research in the context of our current understanding of patterns of evidence in the medical literature. An SBM review would conclude that the scientific basis for the existence of Oscillococcinum is unconvincing to say the least, and actually is rank pseudoscience analogous with N-rays.

Homeopathy itself also qualifies as pseudoscience, because it is at odds with our basic understanding of physics and chemistry. Furthermore, the totality of the homeopathy clinical research is most consistent with a treatment that has no effect. We therefore have an ineffective application of a nonexistent substance. Further, there is no scientific reason to presume that this particularly ^[sic] treatment will be effective for the flu. Finally, the clinical evidence is insufficient (unsurprisingly) to conclude that the treatment works. Taken as a whole it seems that this treatment has no promise and any further research would be such a waste of resources as to be unethical. ...

The core philosophy of SBM is to use the best possible conclusion that science currently has to offer in making clinical decisions (including regulatory ones). This includes the most rigorous clinical studies possible. However, it must also consider preclinical and basic science—all scientific information that can reasonably be applied to the question at hand. This means considering the overall scientific plausibility of any clinical claim. Clinical evidence faces many challenges, including researcher bias, publication bias, and the vagaries of statistical analysis. Most studies that are performed are imperfect ... It often takes decades for clinical research to progress to the point that we have highly rigorous and definitive trials. In the meantime, we have to make decisions based upon imperfect evidence. Basic science plausibility helps put the clinical evidence into context, improving our ability to make reliable decisions based upon preliminary clinical data. That is why I believe that evidence-based medicine should evolve in the direction of science-based medicine. That would be the evidence-based thing to do.^[5]

The last lines are important — SBM doesn't view itself as in a conflict with EBM, but rather an evolution of it, or a re-emphasis on neglected principles.^[6][7] From the 2008 opening post for the SBM blog:

Most relevant to this blog is the focus on clinical trial results to the exclusion of scientific plausibility. The focus on trial results (which, in the EBM lexicon, is what is meant by "evidence") has its utility, but fails to properly deal with medical modalities that lie outside the scientific paradigm, or for which the scientific plausibility ranges from very little to nonexistent.

All of science describes the same reality, and therefore it must (if it is functioning properly) all be mutually compatible. Collectively, science builds one cumulative model of the natural world. This means we can make rational judgments about what is likely to be true based upon what is already well established. This does not necessarily equate to rejecting new ideas out-of-hand, but rather to adjusting the threshold of evidence required to establish a new claim based upon the prior scientific plausibility of the new claim. Failure to do so leads to conclusions and recommendations that are not reliable, and therefore medical practices that are not reliably safe and effective.

This is why the authors of this blog strongly advocate for science-based medicine – the use of the best scientific evidence available, in the light of our cumulative scientific knowledge from all relevant disciplines, in evaluating health claims, practices, and products.^[8]

Contributors[edit]

The editorial staff for SBM writes regularly and includes:^[1]

• Steven Novella, MD
• David Gorski, MD, PhD
• Kimball Atwood, MD
• Mark Crislip, MD
• Harriet Hall, MD

Other contributors for SBM include:^[9]

• Joseph Albietz, MD
• Val Jones, MD
• Peter A. Lipson, MD
• Scott Gavura, BScPhm, MBA, RPh
• Jann Bellamy, JD
• Brennen McKenzie, MA, VMD
• John M. Snyder, MD
• Clay Jones, MD
• James Coyne, PhD
• Ben Kavoussi, MS, PA-C
• Linda Rosa, RN
• Lorne Trottier, CM
• David Weinberg, MD
• Steve Hendry, BSc DDS FAGD
• Sam Homola, DC
• Igor Bussel, BS, MS
• Jim Dougherty, MD, MPH, Brig Gen USAF (ret)
• Olle Kjellin, MD, PhD
• Andrey Pavlov, MD student
• Grant Ritchey, DDS
• David W. Ramey, DVM
• David J. Kroll, PhD
• Timothy Kreider
• Martin Lessem, JD
• Eugenie Mielczarek, BS, MS, PhD

Subjects[edit]

Being a skeptical medical blog, SBM naturally covers relevant subjects of interest that are also part of our purview here at the wiki:

• GreenMedInfo^[10]
• NaturalNews

Retracted article by Harriet Hall[edit]

Harriet Hall was a regular contributor to Science-Based Medicine who normally wrote high-quality content. Some of her later contributions, however, flirted with transphobic viewpoints. Her first few articles on the subject advocated excessive caution about gender transitioning, which was decried by some readers as transphobic. Her first misstep into the shitstorm was her review of Irreversible Damage: The Transgender Craze Seducing Our Daughters, by Abigail Shrier (who was featured in a PragerU video)^{[note 1]} that was largely uncritical despite the obvious fearmongering from the book's cover and even the title.^[11] Hall additionally cited very few sources to back her claims, and it's unclear where she's just describing the book's arguments or if she's endorsing the arguments. The comments in the article were largely critical and highlighted basic inaccuracies (such as the claim that in California it is very easy to get top surgery).

This led to two other SBM editors, David Gorski and Steve Novella, to pull the article and leave a note: "After careful review, the editors of SBM decided to retract this book review. Because we allow trusted authors to publish without prior review for the sake of efficiency and timeliness, occasionally corrections need to be made post-publication. In this case we felt there were too many issues with the treatment of the relevant science, and leaving the article up would not be appropriate given the standards of SBM." The note then says it's not an act of censorship and people can try to respectfully discuss in the comments section, but that didn't stop Michael Shermer from republishing the article in Skeptic.com who initially left a note saying that SBM has a "far-left progressive political bias that has compromised their otherwise stellar reputation as a trustworthy source", though it was later removed from Skeptic's repost.^[12]

See also[edit]

• Ben Goldacre
• Edzard Ernst

External links[edit]

• Science-Based Medicine homepage.
• Science-Based Pharmacy
• Society for Science-Based Medicine, co-founded by some of the SBM bloggers.

Some links on SBM concepts

• "About SBM". Contains a further reading list (contents are thus omitted here).
• Kimball Atwood (2011). "Cochrane is Starting to 'Get' SBM!". Science-Based Medicine. Contains another further reading list (these are also thus omitted here).
• Val Jones (2008). "When Further Research Is NOT Warranted: The 'Wisdom of Crowds' Fallacy". Science-Based Medicine.
• David Gorski (2009). "When fraud undermines science-based medicine". Science-Based Medicine.
• Val Jones (2009). "Science-Based Medicine 101: How To Establish A Source's Credibility". Science-Based Medicine.
• Val Jones (2009). "Science-Based Medicine 101: Plausibility". Science-Based Medicine.
• Val Jones (2009). "Science-Based Medicine 101: Reproducibility". Science-Based Medicine.
• David Gorski (2010). "Lies, damned lies, and…science-based medicine?". Science-Based Medicine.
• Steven Novella (2011). "CAM and Evidenced-Based Medicine". Science-Based Medicine.
• David Gorski (2011). "Answering another criticism of science-based medicine". Science-Based Medicine.
• Harriet Hall (2013). "Philosophy Meets Medicine". Science-Based Medicine.
• Harriet Hall (2015). "Science Based Medicine" (video course). YouTube.
• Steven Novella (2015). "It's Time for Science-Based Medicine". Skeptical Inquirer.
• David Gorski (2016). "The hijacking of evidence-based medicine". Science-Based Medicine.
• James Thomas (2016). "Why Science-Based Medicine Matters". Science-Based Medicine.
• Steven Novella (2017). "Responding to SBM Critics". Science-Based Medicine.
• David Gorski (2022). "Science-based medicine isn't just for CAM. The case of ivermectin shows that it never was.". Science-Based Medicine.

Notes[edit]

References[edit]